Tobacco Cessation

Question 1

pack year smoking history formula

Answer 1

PY = cigarettes/day x years smoked

Question 2

what is the 5 a’s model

Answer 2

ask about tobacco use ( every visit)
advise to quit
assess willingness to make attempt to quit
assist in quit attempt (behavioral therapy, meds, or motivational interviewing to encourage future attempt)
arrange follow up (fu within week for pt willing to make quit attempt, fu at next visit if unwilling)

Question 3

1800QUITNOW Is the national hotline

Question 4

medications should be encouraged along with counseling/behavioral therapy in all pts attempting to quit unless contraindicated

Answer 4

first line:
5 nicotine replacement therapies (NRT): patch, gum, lozenge, inhaler, or nasal spray (short acting, except long acting)
2 non nicotine drugs : bupropion and varenicline (long acting)

combining a short acting NRT with a long acting patch is most effective at reducing cravings. ex: patch with bupropion SR or patch with lozenge

Question 5

EVALI

Answer 5

e cigarrete/vaping product associated lung injury

Question 6

behavioral counseling is preferred over medications for pregnant women, adolescents, smokeless tobacco users, and light smokers

Answer 6

smokers who quit no longer have the CYP1A1 inductions, so they experience supratherapeutic levels of normally dosed theophylline, fluvoxamine, caffeine, olanzapine, clozapine, and R-isomer (the less potent isomer of warfarin)

SMOKING INCREASES BLEEDING RISK ON CLOPIDOGREL AND WARFARIN

Question 7

women who smoke shouldn’t take estrogen containing oral contraceptives because

Answer 7

increases risk of CVD events

Question 8

vaccines for smokers

Answer 8

if ages 19-64, they should get

pneumococal and influenza

Question 9

nicotine patch (nicorderm CQ) otc

Answer 9

initial dose is based on # cigarettes smoked/day

SE: vivid dreams , skin irritation

highest adherance rate, but must remove before MRI

Question 10

Nicotine inhaler (nicotrol)- use up to 6 months
nicotine nasal spray (nicotrol NS) - use up to 3 months

both Rx

Answer 10

this is for the fastest delivery , and is useful for rapid relief of withdrawal symptoms.

it also mimics the hand to mouth smoking action.
this has highest risk of dependence

Nasal spray SE: watery eyes, sneezing, transient changes in taste and smell

Inhaler SE:mouth and throat irritation, sinusitis

Question 11

nicorette lozenge (nicorette mini)
nicotine gum (nicorette) otc

Answer 11

initial dose based on time to first cigarette after waking

these are sugar free.

do not eat or drink 15 minutes before or during use

how to use: chew slowly until there is a tingle or peppery flavor in mouth then park it between gum and cheek until tingle flavor goes away. when it goes away begin to chew and then repeat the steps until most of the flavor/tingle is gone.

Question 12

explain time to cigarette after waking dosing regimen (for gum and lozenge) 12 wks

Answer 12

</= 30 minutes after waking –> 4mg every 1-2h for 6 weeks, then 4 mg q2-4h for 3 weeks then 4 mg q4-8 hours for 3 weeks

> 30 minutes after waking –> 2 mg q1-2 h for 6 weeks ,then 2 mg q2-4 h for 3 weeks, then 2 mg q4-8h for 3 weeks.

BEST to use >/= 9 pieces of gum per day in the first 6 wks

DO NOT EAT/DRINK 15 min before or during use. 4 MG strength helps to reduce or delay weight gain: acidic beverages/foods decrease the buccal absorption

Question 13

explain dosing regimen for number of cigarettes/day. For the patch, used for 8-10 weeks
(1 pack = 20 cigarettes)

Answer 13

> 10 cigarettes/day -
21 mg for 6wks, then 14 mg for 2 wks, then 7 mg for 2 wks

</= 10 cigarettes/day
14 mg for 6 wks, then 7 mg for 2 wks

Question 14

Warnings for NRT

Answer 14

avoid in immediate post heart attack period, life threatening arrhythmias, severe or worsening angina and pregnancy

inhaler/nasal spray: avoid in asthma, COPD, and other chronic respiratory diseases

Question 15

SE of NRT

Answer 15

insomnia, HA, dizziness, nervousness, dyspepsia (indigestion)

Question 16

FDA prohibits sale of nicotine products to ppl < 18

Question 17

buproprion SR (zyban)

wellbutrin SR and XL are the depression/seasonal effective disorder brand names

Answer 17

blocks the reuptake of dopamine and NE. results in reduced cravings and withdrawal sx

dose: START AT LEAST 1 WK BEFORE QUIT DATE. SR- 150 QAM for 3 days, then 150 mg BID . max dose 300 mg /day. use up to 6 months.

BOXED warning for increased risk of suicidal behavior in children, adolescents, and young adults taking antidepressants

contraindications: seizures, hx of bulemia/anorexia, use with MOAi’s linezolid or IV methylene blue, abrupt discontinuation of ethanol or sedatives , do not use with other forms of buproprion

warnings: serious neuropsych events, mania, hypomania, HTN, angle closure glaucoma, rash (including SJS)

SE: dry mouth, insomnia (take 1st upon waking up and 2nd dose 8 hrs later to decrease), tremors, weight loss, agitation, anxiety, tachycardia, HA, sweating, N/V, constipation. delays weight gain,

discontinue if no progress by week 7

Question 18

varenicline (chantix) moa

comes in starting month pack and continuing month pack

Tyrvaya (nasal spray for dry eyes)

Answer 18

partial neuronal alpha4, beta 2 nicotnic receptor agonist. causes low level stimulation of receptor while blocking ability of nicotine to bind. it causes low level stimulation of the receptor but prevents real nicotine from binding

relieves withdrawal sx and inhibits the surges of dopamine responsible for reinforcement/reward assoc. with real smoking

start 1 week before quit date.

days 1-3 use 0.5 mg daily
days 4-7 use 0.5 mg BID
day8 (quit date and beyond) use 1 mg BID

use for 12 weeks. could do 24 total to maintain success

CrCl,< 30 ml/min, used 0,5 mg daily titrated to max 0.5 BID

warnings: serious neuropathic events, depression, suicide ideation, seizures, increased effects of alcohol, sleepwalking (somnambuism, accidental injury, CVD risk, hypersensitivity rxns.

SE: nausea, insomnia, abnormal dreams, HA, constipation, flatulence, vomiting,

to reduce nausea, take after eating and drinking full glass of water, reduce dose prn

to decrease insomnia, take second dose earlier than bedtime.

if unable to quit on day 8 smoking. decrease the smoking by 50% in first 4 weeks, ,then quit another 50% during week 5-8 and quit by week 12.

not recommended for < 16

Question 19

varenicline and bupropion dont need to be tapered when DCd

Answer 19

remember that pts on varenicline and bupropion need to start 1 week before quit date since the drug helps reduce withdrawal

Question 20

if pt is concerned about weight gain and wants to quit

Answer 20

use gum, lozenge, and bupropion SR because they all delay weight gain

Question 21

if pt has depression and wants to quit

Answer 21

use bupropion SR

Question 22

it pt has dentures and wants to quit obviously avoid the gum

Answer 22

if pt has asthma or copd and wants to quit, avoid inhalers or nasal sprays

Question 23

if pt has seizures and wants to quit avoid

Answer 23

avoid bupropion and varenicline

Question 24

if pt has a skin condition and wants to quit obviously avoid the patch

Question 25

counseling for nicotine patch

Answer 25

use new patch each day, save the pouch the patches come from to throw away the old patch (fold it first).

press new patch on clean dry hairless area for 10 seconds firmly

wear for 24 hrs esp. if cravings begin upon waking
can remove patch before bedtime (after 16 hrs) if having vivid dreams and apply new one in the morning.

never cut or wear multiple patches
rotate application site . each application spot should get a week break

Question 26

how to use nicotine nasal spray

Answer 26

tilt head back slightly and spray once/nostril while breathing through the mouth

no inhaling through nose or sniffing or swallowing

Question 27

never use more than one lozenge at a time or continuously use lozenges one after the other

Answer 27

varenicline and bupropion cause suicide ideation and insomnia

varenicline additionally causes nausea which can be improved with dose changes

reduce amount of alcohol intake while on varenicline because it can increase alcohols effects